Two Major Developments in Psychiatry

Jeffrey A. Lieberman, MD


May 12, 2017


Hello. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today from Medscape. My last video post described how "I am mad as hell and I am not going to take it anymore," and I think it really signaled the frustration that I wanted to express about the macroenvironment that physicians, healthcare providers, and researchers are constrained by in our country today and have been for too many years.

I am going to post a sequel to that video blog for my next post. However, not wanting to convey to the viewing audience too much depressing news on a consistent basis, I thought that I would interject with some good news.

The reason for the good news is because of two recent developments that I view as very encouraging in terms of what we—meaning, mental health care providers, psychiatrists, psychologists, social workers, and therapists—can do if we work collaboratively, constructively, and with the common goal of serving the patient populations that we are supposed to be committed to treating, and also to rigorously and relentlessly pursue the truth in understanding the nature of human disease and the ability of treatments to alleviate their symptoms and suffering associated with them.

The two things that occasioned my optimism and more sunny comments today are, first, the announcement of something that has been ongoing since May 2013, the date on which the DSM-5 was released. In the aftermath of that, a process to establish a mechanism for this document to be amended, updated, changed, as evidence warrants doing so.

Now, this process has taken until January 2017 to come to fruition, but at the time, the APA announced the establishment of a DSM Steering Committee, which would be able to entertain any proposals for changes that would be warranted by new scientific findings or clinical developments in mental health care. In doing so, this is the first step of creating a virtual living document of the psychiatric nosology that all mental health providers use.

If anybody wants the specifics of this, there is an article that was published in November 2016 in JAMA Psychiatry, co-authored by Ken Kendler, which describes the DSM Steering Committee and its procedures for operations.[1] In essence, this is a committee comprising experts in psychiatric nosology, research clinical psychiatry, and mental health care, and who were involved with the formation of the DSM-5. It also includes representatives of the different constituencies of the APA, including the Board of Trustees and the Assembly, plus ex officio membership of the leaders or their designees from the relevant NIH institutes, such as the NIMH, NIDA, and NIAAA. There is also representation from the WHO, which of course produces the ICD.

This committee is chaired by Paul Appelbaum, past president of the APA and Columbia faculty member. It is co-chaired by Ken Kendler, distinguished psychiatric geneticist and researcher at the Medical College of Virginia, and Ellen Leibenluft, a distinguished researcher in mood disorders in pediatrics who has been at the NIMH.

[C]hanges can be made and will be made because of the fact that we live in the digital age of the Internet and are no longer bound by hard-copy publications. This is a real innovation.

The committee is the overall arbiter of proposed changes but it comprises five standing committees that have approximately six members each, who work with the steering committee to review any proposals for revisions that are received and vet them in terms of their justification and evidentiary basis. In doing so, this requires literature reviews, expert consultations, and much discussion. A very high bar is established for anything submitted to warrant actual changes, but changes can be made and will be made because of the fact that we live in the digital age of the Internet and are no longer bound by hard-copy publications. This is a real innovation.

I say that with some degree of pride because of the fact that the DSM, which has been a long-standing instrument critical to psychiatry and mental health care, in its last iteration, has been the target of vicious criticism. The period from when it began, in 2006, to when it was launched, in 2013, was one in which there was an increasing crescendo of criticism in the media, mainly led by antipsychiatry critics. These individuals were in large part nonbelievers in mental illness and the efficacy of scientific competence of psychiatry—individuals from Scientologists to rabid ideologues, to those who are antimedicine and antiscience. This played out in the media. Indeed, there was so much criticism that I found myself, as the president-elect and then president of this latter stage of the process, having to almost continually answer questions and defend the process and the integrity of the DSM in the media.

These individuals were in large part nonbelievers in mental illness and the efficacy of scientific competence of psychiatry.

Despite all of this, DSM-5 was launched in May 2013 and has been successfully disseminated and implemented. It has received a very favorable response from clinicians who use the instrument. Now, with the process of establishing this steering committee, which is chaired by individuals of impeccable credentials, we can ensure the ability of this document to change with new scientific and clinical findings. It is based on scholarship and scientific evidence, and should be immune to the type of influences that are often perceived by critics in terms of corruption, self-interested providers, or pharmaceutical or device companies.

All of the members of the committee, as well as its leadership, have been carefully vetted for conflict of interest. This is something that the APA feels very proud of, and I personally feel that this is the final step in what has often been a very tumultuous process.

A Major Analysis on Antipsychotic Efficacy

The second thing that I am very happy to report on is a positive development and a beacon of the fidelity that underpins the medical profession and all of life sciences—that is, a commitment to research and the discovery of knowledge and truth based on evidence. I'm referring to a new publication that was posted online in the American Journal of Psychiatry on May 5, 2017.[2] It is an article that is lead-authored by Don Goff of NYU and the Nathan Kline Institute and which comprises coauthors from various countries around the world who are international experts in the area of psychopharmacologies, schizophrenia, and antipsychotic drugs.

I myself had the privilege of participating in this process. It was a process in which the evidence for the effectiveness, or lack thereof, of antipsychotic drugs and long-term outcomes of schizophrenia was reviewed in a very rigorous, comprehensive way. What occasioned this effort and convening this group of experts was the fact that, over the years, despite the triumph of psychopharmacology reflected in mood disorders, anxiety disorders, psychotic disorders, attentional and cognitive disturbances, there are continual critics, again coming largely from various constituencies in the antipsychiatry movement, who have assailed the efficacy of these treatments. These treatments were serendipitously discovered, but they have then been studied and found to be optimally applied to alleviate the symptoms of disorders like bipolar disorder, depression, schizophrenia, and schizoaffective disorder, which for centuries had disabled and caused suffering in humankind.

The critics of antipsychotics claim that rather than being therapeutic and alleviating symptoms, improving outcomes, and enabling recovery, these drugs are counterproductive and lead to poor outcomes. The evidence they cited was a variety of different longitudinal and brain imaging studies. However, the bases on which they leveled these criticisms involved distorting study findings and/or using fragmentary evidence or citing evidence from studies that were methodologically flawed.

In order to really countermand this process and find out whether antipsychotic drugs indeed have not only short-term therapeutic effects but also beneficial long-term effects, a group of experts came together and decided to review the literature rigorously and examine different lines of evidence. The evidence examined ranged from acute treatment studies to relapse-prevention studies, to long-term outcomes studies to brain imaging studies, to studies of neuropathology involving postmortem tissue from individuals who were exposed to treatment during their lifetime. It came to a very firm conclusion as to the unquestionably positive benefit of these drugs.

Now, this is reassuring and not entirely surprising. But it is incredibly important because of the fact that without a benchmark study or analysis in publication, unsuspecting people with, say, family members affected by psychotic disorders needing treatment with antipsychotic drugs, or receiving treatment with antipsychotic drugs, might not accept [an effective] treatment or they may discontinue treatment [based on unfounded criticisms].

The critics who gave rise to this notion that antipsychotic treatment adversely affects long-term outcomes were sowing seeds of untruth and, in their pursuit of some ideological goal or need for self-serving acclamations, were ignoring entirely the harm that they were causing many people who unwittingly would accept these as credible statements and follow their guidance. As I film this video, the contents of the new article are embargoed, so I cannot reveal the contents just yet. But let me just say that this is an extremely well-composed paper that provides a scholarly and rigorous review of relevant lines of evidence. It comes to a very clear and definitive conclusion that we all should take note of the findings, apply them in our clinical practices, and use them where need be in the education of patients and against the reputation of individuals who are really trying to create mischief for their own nefarious purposes.

These I regard as positive developments in what has become a struggle on multiple fronts to advance the cause of mental health care, the pursuit of scientific knowledge in regard to brain function and mental illness, and to advance the practice of psychiatry.

Thank you for listening. From Medscape, this is Dr Jeffrey Lieberman, Columbia University.


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